First Opinion readers respond to psychiatry and social contracts, Medicare and weight loss meds, and more

First Opinion is STAT’s platform for interesting, illuminating, and maybe even provocative articles about the life sciences writ large, written by biotech insiders, health care workers, researchers, and others.

To encourage robust, good-faith discussion about issues raised in First Opinion essays, STAT publishes selected Letters to the Editor received in response to them. You can submit a Letter to the Editor here, or find the submission form at the end of any First Opinion essay.

“Psychiatrists aren’t fulfilling the social contract that subsidized their training,” by Richard G. Frank

While I appreciate the sentiment, this article is incomplete at best, and oversimplifies a complex calculus. Physician training is, of course, subsidized by the Medicare and Medicaid systems; most residency positions are, and not just in psychiatry. However, are we leveling this at the other specialty physicians who are not accepting Medicare and Medicaid patients? Additionally, the reimbursement in psychiatry is not level — it is much more limited and not equitable compared to other specialties, particularly surgical/procedural specialties. This makes it harder for psychiatrists to pay the bills when accepting a lower rate of reimbursement than other physicians even though the student loan bills are still there.

I agree that the social-ethical contract is compelling for psychiatrists to accept all of these patients. However, substantial deficits and inequities in the health care systems shouldn’t be placed on psychiatrists to take sole responsibility for.

At the same time that we should encourage psychiatrists to accept a wider range of patients, we should also be calling out the inequities in the payment system, mental health “parity” laws that are largely unenforced (and thus meaningless) rendering an unfair system for patients seeking care and psychiatrists seeking reimbursement for care provided.

As with most issues in health care, it’s complicated.

— Michael J. Peterson, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health

***

Thanks for reminding me of my “social contract.” I need a favor: review the back door meetings of the Medicare Act of 1965 that resulted in non-procedure based care being reimbursed (and considered less important) than procedure-based care. Give us the demographics of these decision-makers (I’m assuming all cisgendered heterosexual white guys). Share with us how extrapolating this built-in financial discrimination has resulted in psychiatrists not taking insurance. In other words: do real research before throwing stones in glass houses.

— Brian Dixon

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This article ignores the very obvious elephant in the room. It implies that the money paid by Medicaid/Medicare to support psychiatry residents actually translates into some kind of fair compensation for their work during residency. Residents work 60-80 hours per week during residency. In return we are paid somewhere between $40,000 and $60,000 a year at the beginning of our training, which grows to somewhere between $50,000 to $70,000 by the end. In short, we are paid about $19 per hour for some of the most highly skilled work in the country. I think that fulfills our social contract quite nicely.

— Karen Abdool

***

While Richard G. Frank’s recent First Opinion piece calls attention to the problem of lack of access to mental health services, it inappropriately lays blame for that problem at the feet of psychiatrists. To the contrary, psychiatrists are working within complex systems and advocating fiercely to ensure the widespread provision of quality care.

For those who are choosing not to take insurance, the simple truth is that the finances don’t add up. Psychiatrists leave training with medical school debt, are paid less per hour than primary care physicians and even physician assistants, and need to spend time or dollars on staff to help deal with administrative complexities like prior authorization. As Frank points out, insurers, in an effort to cut their own costs, have limited networks, established inadequate fee schedules, and created administrative barriers to mental health services. This leaves psychiatrists in a bind when trying to serve patients without going into the red: and still, only 7.7% of psychiatrists have opted out of Medicare. Many of our members and colleagues clearly want to take insurance, including Medicare and Medicaid, but in this reality, sometimes we can’t.

We want this situation to change and we are working hard on solutions. Advocacy for mental health parity is imperative. Parity won’t be achieved without adequate reimbursement, and we are working with the Center for Medicare and Medicaid services and public and private payors to achieve it.

Meanwhile, demand for psychiatric services has grown exponentially, and we cannot increase the number of psychiatrists fast enough to meet this need. While more graduate medical examination slots have been created in recent years and the field is more popular than ever, our physician members advocate to ensure we maintain a strong pipeline to bring in more qualified psychiatrists.

Psychiatrists are also on the forefront of advocating for transformative care delivery models and modalities that will allow for better access, including telepsychiatry, and team-based care to expand access for all individuals. Whether through integrated care options like Collaborative Care or working on teams in other models, we’re innovating to reach patients like never before.

The failure is not one of individual choices, but rather a systemic failure to fund and support access to psychiatric care. As it stands today, the field is forced to leverage its scarce resources to serve the needs of a country facing a mental health crisis.

— Marketa Wills, M.D., CEO and medical director of the American Psychiatric Association

“Medicare should wait on approving coverage for Wegovy,” by Alissa S. Chen

Although by a thoughtful doctor, this article is heavy on feelings and short on empirical arguments. You may feel like it is not a good idea, and that can be your personal belief, but that does not warrant its being used as evidence against a treatment that has been clinically demonstrated to have benefits beyond weight loss. Research on older patients is scarce but where isn’t that the case except for drugs intended to ameliorate dementia? How long do we wait before trying this apparently efficacious treatment?

— Steven Struhl, Converge Analytic

***

Please do not minimize semaglutide by equating it as merely affecting appetite to counteract “late night snacking.” The SELECT trial demonstrated that in persons with BMI of 27 or higher and without diabetes who had prior heart attack, stroke or peripheral artery disease, taking semaglutide versus placebo was associated with 20% reduction in subsequent heart attack, stroke and cardiovascular death! (Disclosure: I co-chaired the Steering Committee for SELECT and have received compensation for consulting from Novo Nordisk and many other makers of obesity medications and devices.)

This landmark study is important knowledge for every physician, and especially those in obesity medicine. The SELECT trial studied 17,706 patients and more than 6,000 were age 65 or older. It used the most rigorous methodology and was executed with precision. The FDA gave Wegovy an indication for secondary prevention of cardiovascular disease after rigorous review.

Let’s be serious about offering this medication to people who need it. It is not a lifestyle medication. Medicare made the right decision in providing reimbursement for secondary prevention of cardiovascular disease.

— Donna Ryan, Pennington Biomedical Research Center

***

As a patient, I’m disappointed we have experts encouraging Medicare NOT to pay for semaglutide and tirzepatide. I am 69 years old and I go to my PCP’s office weekly to get my injection administered. The entire cost is $350 for semaglutide for four weeks, and $450 for the tirzepatide for four weeks. I have been doing this for 14 months, had no adverse side effects whatsoever and have lost 50+ pounds thus far. While this is doable for me, I realize many others are not as fortunate. I would like to see Medicare follow the lead of private insurers and start covering part or all of the cost.

— Penny Ogden

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I’m 66 and started on prescription Zepbound in February of 2024. I have lost weight, blood pressure is down, not sure about cholesterol though. Not only does Medicare not pay for it but they also do not allow us to get the huge discount coupon from the manufacturer. Not really sure if I’ll be able to afford this medication much longer, which is quite sad.

— Tracey Black

***

As a 68-year-old female who has taken Ozempic for 17 months and had it ripped away with Medicare deciding not to cover it for those with pre-diabetes, I have to say I feel much worse now that the weight has come back, along with incessant hunger. In four months my A1C, blood pressure, and cholesterol went up. My life is again centered around what I can and should not eat and it is a constant battle that can be won short term, but not long term.

Ozempic helped my weight stay constant. I loved the once a week shot and then could forget about it. I drank lots of water and got plenty of exercise. Clothes felt good. Now it is depressing. Can’t move as well, nothing fits and just can’t get my weight to stop climbing no matter how much I exercise. Medicare should approve this treatment for older people. Let each doctor decide by patient if it should be used, not the government!

— S R Bratton

“Congress called for an ALS moonshot. The plan for it doesn’t leave Earth,” by Bernie Zipprich

This is an excerpt of my testimony to the National Academies of Sciences, Engineering, and Medicine on my plan to make ALS a livable disease in 10 years:

With veterans 60% more likely to develop ALS, it is imperative that we serve those who’ve served in the armed forces. Nonprofit organizations like Paralyzed Veterans of America (PVA) are uniquely staffed with national service officers who are ALS benefits experts. In partnership with the Veterans Administration, PVA’s Medical Services team conducts site visits across the country, engaging with ALS specialists.

It was on such a visit that I met Dr. Richard Reimer, medical director of the ALS Clinic at the Palo Alto VA. Collaborating with the Lawrence Livermore National Lab, Dr. Reimer is using its world-class supercomputer, investigating drugs to repurpose for ALS.

Another study, facilitated by The National ALS Registry, assesses “Military exposures and ALS in a large Veteran population.” Data from the Department of Defense and VA will capture military factors such as branch of service, occupation, deployment, demographic, and de-identified health data.

According to a Project MinE study, 15% of people with Sporadic ALS have a genetic component while regional fine-mapping has identified an additional 690 new ALS-risk genes. This supports the opinion that ALS has multifactorial causes and that genetic testing should be routinely offered as a standard of care.

In conclusion, I would like to echo the sentiments of Retired Marine Corps infantry officer, Chris Mulholland, who has been battling ALS since November 2020. In a Military Times article titled, “ALS is Killing Veterans,” Chris wrote, “If you know of a Veteran who has – or had ALS, we need you in this fight. Too often ALS exists in the shadows, and those afflicted pass so quickly they can’t speak for themselves. Be their voice!”

— Juliet Pierce, Paralyzed Veterans of America